Some Laryngopharyngeal Reflux Resists PPI Treatment

Dr. DelGaudio suggested a few other conditions otolaryngologists should rule out: increased tone (hypertonicity) in the upper esophageal sphincter, the presence of masses in the pharynx or larynx and whether cervical osteophytes are impinging on the laryngopharyngeal area. “Age and weight can increase the risk of LPR, as can hiatal hernia, other issues with stomach emptying and esophageal musculature,” he said.

When reevaluating a patient, consider that there could be reflux other than the common acidic reflux. “It could be weakly acidic reflux, which is more difficult to treat, or even nonacidic reflux,” said Dr. DelGaudio. In those cases, PPIs are not going to be as effective, and otolaryngologists may want to consider fundoplication surgery, which strengthens the lower esophageal sphincter and diminishes reflux. This allows the esophagus and the larynx to heal.

Other pathologies can result from chronic LPR. “When you regurgitate stomach contents, enzymes like pepsin stick to the lining of the throat. Then every acid episode (either food going down or reflux coming up) interacts with the pepsin and starts to digest the larynx,” Dr. Altman said. Once the pepsin is seeded, it leads to a condition with a complex physiology—too complex for PPIs to restore, because they only treat the acid component.

A strict low-acid diet may be helpful in nonresponsive patients, according to a recent study of 20 patients with LPR who had failed to respond to twice-daily PPI treatment and H2 block at bedtime (Ann Otol Rhinol Laryngol. 2011;120:281-287). The researchers put the patients on a strict low-acid diet for two weeks, in which all foods and beverages with pH levels lower than five were eliminated from the diet. Improvement was seen in 19 people and complete resolution of symptoms in three.

Dr. Courey approaches the diagnosis more broadly from the get-go. “Reflux symptoms are really nonspecific indicators of laryngeal irritation,” he said. “Yes, reflux could be the problem, but it’s not the only possibility.” He advocates behavioral therapy, specifically voice therapy, to lessen the stress on the larynx. “We work with patients to increase the efficiency of voice production,” he added, which includes sessions with a vocal pathologist to enhance voice coordination, respiratory support and laryngeal action, trying to get patients to feel the balance among those three components of voice production.

Furthermore, Dr. Courey said 75 percent of his patients are helped by this approach, and have measurable reductions in their reflux symptom index score. “Is it a placebo effect? Maybe, but it doesn’t matter. It’s better than taking a pill with side effects,” he said.